DOS-1628-f (Rev. 02/23) Page 1 of 2
New York State
Department of State
Division of Licensing Services
Security Guard
P.O. BOX 22052
Albany, NY 12201-2052
Customer Service: (518) 474- 7569
https://dos.ny.gov
Proprietary Security Guard Employer
Please take the time to read the instructions in this package
carefully before beginning the application form.
When would I be required to submit a Proprietary
Security Guard Employer form?
Any private or public entity employing individuals, other than peace
and police officers, to perform security services is regulated by the
New York State Department of State.
Do Security Guards employed by proprietary entities
need to register and complete training?
Yes. Although proprietary employers of security guards are exempt
from the business licensing requirement, they are still considered to
be Security Guard Companies under the law. As such, they are
required to employ registered security guards and provide proof of
self-insurance or liability insurance coverage. A proprietary
employer must designate a Security Guard Coordinator to provide
the Department of State with the necessary information.
What is a Security Guard?
A Security Guard is defined as: Any individual who is employed to
principally perform any or all of the following duties, and the person
is not performing the functions of a private investigator as defined in
Section 71 of Article 7 of the General Business Law.
• Prevention, protecting persons and/or property from
harm, theft, and/or unlawful activity, including response to
a security system alarm; or
• Deterrence, such category shall include: deterring,
observing, detecting and reporting unlawful or
unauthorized activity; or
• Control, controlling, by street or other patrol service,
access to property, including employee personnel, visitors,
vehicles and traffic; or
• Enforcement, enforcing security policies, rules,
regulations, and procedures; or
• Any individual who is employed to perform any or all of
the above duties, irrespective of whether such duties
constitute a principal part of such individual’s employment,
with the condition of such employment being that s/he is
armed with a weapon.
“Security Guards” do not include doorperson, superintendent,
handyperson, porter, elevator operator, private investigator,
proprietary investigator, telephone operator, lifeguard, school
crossing guard, receptionist, clerical person, resident advisor or
assistant, parking lot attendant or assistant, fire safety director or
fire inspector, fireguard, environmental safety person, or any other
title which shall not require such person, to perform any or all of the
above functions more than 50% of the person’s regularly scheduled
work hours.
Do I need to have insurance?
Yes. Section 89-g sub. 6 of Article 7A requires the filing of a
certificate of insurance evidencing comprehensive general liability
coverage in the minimum amount of $100,000 per occurrence and
$300,000 in the aggregate.
What are the fees?
No fee is required to file this application. However, the appropriate
fee must accompany each security guard application filed with the
Department of State.
PRIVACY NOTIFICATION
Do I need to provide my Social Security and federal ID
numbers on the application?
Yes, if you have a social security number or Federal ID number,
you are required to provide this number. If you do not have a social
security number of Federal ID number, please provide a written
explanation.
The Department of State is required to collect the federal Social
Security and Employer Identification numbers of all licensees. The
authority to request and maintain such personal information is
found in §5 of the Tax Law and §3-503 of the General Obligations
Law. Disclosure by you is mandatory. The information is collected
to enable the Department of Taxation and Finance to identify
individuals, businesses and others who have been delinquent in
filing tax returns or may have underestimated their tax liabilities and
to generally identify persons affected by the taxes administered by
the Commission of Taxation and Finance. It will be used for tax
administration purposes and any other purpose authorized by the
Tax Law and may also be used by child support enforcement
agencies or their authorized representatives of this state or other
states established pursuant to Title IV-D of the Social Security Act,
to establish, modify or enforce an order of support, but will not be
available to the public. A written explanation is required where no
number is provided. This information will be maintained in the
Licensing Information System by the Direction of Administration
and Management, at One Commerce Plaza, 99 Washington
Avenue, Albany, NY 12231-0001.
WOULD YOU LIKE TO REGISTER TO VOTE?
Please visit the NY State Board of Elections at www.elections.ny.gov/votingregister.html
or call 1-800-FOR-VOTE to request a NYS Voter Registration form.
To register online, please visit www.ny.gov/services/register-vote.
DOS-1628-f (Rev. 02/23) Page 2 of 2
LICENSE FEE
EXEMPT
New York State
Department of State
Division of Licensing Services
Security Guard
P.O. BOX 22052
Albany, NY 12201-2052
Customer Service: (518) 474- 7569
https://dos.ny.gov
Proprietary Security Guard Employer
BUSINESS INFORMATION
Please PRINT CLEARLY in blue or black INK using ALL CAPITAL LETTERS. Example:
Federal Taxpayer ID:
(See instructions - Privacy Notification)
Business
Name:
DBA Name
(IF APPLICABLE):
STREET ADDRESS (Required – PO Box may be added below to ensure delivery)
Business
Address:
APT/UNIT/PO BOX
CITY
STATE ZIP-CODE ZIP + 4
-
COUNTY
PHONE NUMBER (Including Area Code) FAX NUMBER – IF ANY (Including Area Code)
( )
-
( ) -
E-MAIL ADDRESS – IF ANY
YES NO
1. I have attached proof of self-insurance or liability insurance coverage ………………………………………………..
2. I have attached the certificate of insurance evidencing comprehensive general liability coverage in the minimum
amount of $100,000 per occurrence and $300,000 in the aggregate ………………………………………………….
LAST NAME
Coordinator’s
Name
FIRST NAME MIDDLE NAME
NAME SUFFIX
(e.g., Sr/Jr/III)
Entities exempt from licensing requirement of Article 7 must comply with all other sections of Article 7A and all rules and regulations
promulgated thereof.
X
Applicant’s Signature Date Signed
Below: Please enter any Unique Identification Number(s) previously assigned to the business by the Division of Licensing Services:
Applicant please initial in box
A
B
C
1
2
3
Become an Organ and Tissue Donor
Organ donors save lives. If you would like to be an organ and tissue donor upon your death, you may enroll in the
NYS Donate Life Registry online at www.donatelife.ny.gov/register or complete the form below. Completed forms
should be sent to the NYS Donate Life Registry by email --- [email protected] or, mail - NYS Donate Life
Registry, 185 Jordon Road, Troy, NY 12180.
Fields with an asterisk (*) are required for enrollment. Upon receipt of your completed enrollment form, you will be
sent an email or letter confirming your enrollment and providing you with information on how to limit your donation.
I understand that by opting out of enrolling in the NYS Donate Life Registry, or skipping this question, will not impact
or impair my ability to obtain services from the New York Department of State, Division of Licensing Services.
*Last name
*First name
Middle Initial Suffix
*Address
*Apt. Number *Zip Code
*City
*Birth date / / *Gender M
F
MM DD YYYY
Email address
DMV or IDNYC Number
By signing below, you certify that you are:
• 16 years of age or older;
• Consenting to donate your organs and tissues for
transplantation and/or research in the event of your death;
• Authorizing the New York Department of State, Division of
Licensing Services to transfer your name and identifying
information to the NYS Donate Life Registry for
enrollment;
and
• Authorizing the Registry to give access to this information
to federally regulated organ procurement organizations
and NYS-licensed tissue and eye banks and others
approved by the NYS Commissioner of Health in the event
of your death.
*Sign *Date
